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["Referral Review Reimbursement Request",null,null,"Date Submitted:"]
[null,null,null,"Review Month & YR:"]
[" Provider Name:",null,null,"Provider 1 ID:"]
[null,"Resource Manager:"]
[null,null,null,null,"RM Use Only"]
["Referral Last Name","Referral First Name","Date Rcvd Full Pckt","Full Pckt Response Date","RM Verification"]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[null,null,null,null,null,false]
[{"$f":"COUNTIF(F6:F42,TRUE)","v":0},"Packets","@ 171.48/packet ",{"$f":"SUM(A43*171.48)","v":0}]
["Comments:"]
[]
["By submitting this reimbursement request, the provider is attesting that timelines identified in DDA Policy 4.02 have been fulfilled.  "]
["PAYMENT AND AUTHORIZATION"]
["RM REVIEWING & AUTHORIZING PAYMENT / DATE",null,null,"TOTAL AUTHORIZED:"]
[null,null,null,"SERVICE CODE:"]
[null,null,null,null,"revised 1/25"]